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Prescribing Newsletter

Produced by Herefordshire CCG Medicines Optimisation Team September 2016 Deprescribing: calculating burden

Anticholinergic burden (ACB) has been linked to impaired STOP PRESS! cognition, falls risk and increased morbidity & mortality. Key drug groups include , , Prescribing and drugs for overactive bladder (OAB).  Over half (54%) of all deaths related to drug poisoning in Suggested target groups for deprescribing reviews 2015 involved an opioid drug with your practice pharmacist include:  Consider the quantities on  >75yrs and frail including many in care homes prescription and the risk of  Housebound / vulnerable misuse / diversion on the black  Polypharmacy eg 10-15 items market  Breathless at rest or minimal exertion  Recent feedback from the SW  Indications of shortened life expectancy, progressive Region noted big problems weight loss (>10% over last six months) with misuse of Oramorph® The table below is a guide to calculating ACB solution – consider standard An ACB score of greater than 3 is clinically relevant: release tablets eg Score 1 Score 2 Score 3 Sevredol® as alternative Atenolol & most , ,  Prescribe patch preparations beta-blockers most by brand eg fentanyl as Buproprion & and Matrifen® brand. New brands sedating antihistamines of patches are Chlorthalidone Dicyclomine being reviewed as part of a & Methotrimeprazine Hyoscine chronic pain review ()  The Faculty of Pain website Codeine & other & most contains some useful opiates atypicals resources in the & , non-sedating Aware section. other benzos antihistamines & most Digoxin Mirabegron▼ prescribing is on incontinence meds the increase; see OAB guidelines & & most (flowchart p6) for place in therapy. other diuretics SSRIs Reminder of the MHRA guidance October 2015: See deprescribing section of the internet for more info.  Mirabegron is contraindicated in patients with severe ScriptSwitch Corner uncontrolled hypertension (systolic BP ≥180 mm Hg or A new MR capsule brand Vensir diastolic BP ≥110 mm Hg, or XL® has been added to formulary as an both) option for those patients who do not tolerate  Measure BP before starting or have poor adherence to twice daily treatment and monitor standard tablets. Vensir XL® are 94% more cost effective regularly during treatment, than generically prescribed MR capsules with a potential especially in patients with cost saving for Herefordshire of £80k. hypertension , vitamin D, metformin MR messages and  Report suspected side effects switches have been updated – see August 2016 newsletter. to mirabegron via Yellow Card Some information messages appearing at reauthorisation guidelines – minor and negative saving switches have been removed in Vitamin D response to feedback from practices. Look for the feedback update including clarification of button when a switch or information message pops up, all formulation ( vs capsule) suggestions welcome! and cost information.

The information contained in this newsletter is issued on the understanding that it is the best available from the resources at our disposal at the time of issue. Comments, suggestions, contributions welcome! Medicines Optimisation Team [email protected]

Low Priority Treatment Policy Update – Medicines Section The medicines section of the CCG Low Priority Treatment Policy has been updated and Version 1.0 in a new format can be found on the CCG Medicines Optimisation internet: http://www.herefordshireccg.nhs.uk/low-priority-medicines. Products are grouped where possible and are cross referenced with a rationale for their inclusion in the Policy. Use “Control” and “F” to search for a particular item. New lines include:  OTC medicines which can be bought over the counter for self-limiting conditions including those for analgesia. The community pharmacy section of the CCG website contains advice on self-care and stocking a safe home medicines cabinet  Orlistat –not recommended for prescribing by GPs in primary care and can only be used as part of wider weight management plan in line with NICE under dietetic advice  Head lice lotions and combs  Community dental products e.g. fluoride toothpastes and fluoride mouthwashes – all prescribing to be retained by community dentists, including repeat prescriptions  Liothyronine – contact your practice pharmacist to help with reviews and see the PrescQIPP liothyronine bulletin B121 for more information on this national initiative  New vitamin and mineral products e.g. Macushield® supplement Further updates are planned with the definitive version on the CCG website at any one time; patient template letters and leaflets are available from your practice pharmacist. The current Herefordshire CCG spend on LPT medicines is £429k (based on Q1 16/17 spend). A set of LPT graphs (Q1 16/17) and the top 6 CCG LPT areas are attached as an appendix for Herefordshire practices. Individual practice prescribing data will follow shortly for each practice to review existing prescribing. ScriptSwitch messages are being updated to help manage new patient requests. “Black List” medicines included within the local LPT policy are classified as “black” i.e. not recommended for prescribing by primary or secondary care except under exceptional clinical circumstances. The A-Z formulary checklist is being updated to include new LPT lines.

Dosulepin Updated dosulepin guidance is now available on the Medicines Optimisation website containing information on the following:  safer alternatives to dosulepin  background evidence including the NICE “do-not-do” recommendation for dosulepin in depression  options for local medication review and practice audit – contact the Medicines Optimisation team for an audit template and/or pharmacist support  resources / links eg discontinuation guidelines within the PrescQIPP bulletin

Medicines Optimisation Newsletter produced by Herefordshire CCG September 2016